Commentary
Addressing inequities in access to quality health care
for indigenous people
David Peiris MBBS MIPH, Alex Brown BMed MPH, Alan Cass MBBS PhD
@@ See related research paper by Gao and colleagues, page 1007
M
any issues influence access to quality health care
for indigenous people. In this issue of CMAJ, Gao
and colleagues1 describe inequities in access to
health care and service utilization among Canadian Aborig-
inal people with chronic kidney disease. Similar findings
have been reported in Australia,2 New Zealand3 and the
United States.4 Although well-conducted studies that quan-
tify the extent of the disparity and trends in health care ac-
cess are needed, addressing the underlying causes of this
disparity is a priority not merely because such disparities
are unacceptable but because disparities in access contribute
to major and avoidable ill health.
One key contextual barrier to accessing health care that has
been described in the literature from Australia, Canada, New
Zealand and the US is the continuing impact of colonization.5
The Canadian Royal Commission on Aboriginal Peoples and
the Australian Royal Commission on Aboriginal Deaths in
Custody comprehensively documented the contemporary ef-
fects of past discriminatory policies on indigenous people.6,7
Although few empirical studies have examined the health
effects of discriminatory policies, a well-conducted cohort
study in Australia reported that the forced removal of Aborig-
inal children from their families affected health for genera-
tions.8 By engendering distrust in government agencies, pol-
icies such as these contribute to high levels of stress among
indigenous people. Psychosocial stress, a phenomenon com-
mon to many vulnerable populations, is an important barrier to
accessing health care and has been consistently associated
with adverse health outcomes for indigenous people.9
Health care systems and health care services are not im-
mune from this historical policy context. Studies, predomin-
antly with qualitative designs, have shown that indigenous peo-
ple are sensitive to power imbalances in their interactions with
health care services. This is intimately linked with the domi-
nance of the biomedical paradigm and the view that noncom-
pliant behaviours by indigenous people are the cause of poor
health outcomes. By contrast, when care providers promote a
nonbiomedical approach to health care interactions, through
trust, reciprocity and shared decision-making, they can em-
power recipients and more effectively deliver interventions to
reduce the gap in health outcomes. Much work focuses on mis-
communication as an access barrier.10 Relevant factors include
communication dynamics and sharing of health information,
DOI:10.1503/cmaj.081445
language and literacy. In health care for indigenous people, the
power dynamic directly affects communication.
A related, complex area is the attribution of cultural factors
as both barriers to and facilitators of health care. There is a
clear need to abandon stereotypical concepts of indigenous
cultures and the simplistic embrace of particular culture-based
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
CMAJ NOVEMBER 4, 2008 179(10)
2008 Canadian Medical Association or its licensors
Key points
Inequities in access to necessary health care are unaccept-
able and contribute to gaps in health status between
indigenous and non-indigenous people.
Access barriers exist in patientprovider interactions,
health services and health systems.
Indigenous perspectives on access barriers are poorly
represented and undervalued in the scientific literature.
Consider moving toward the concept of cultural safety
rather than a checklist approach.
ingredients as means of transforming services into becoming
appropriate, aware, sensitive or competent terms
that are often poorly defined. The more dynamic concept of
cultural safety, originally developed by Maori nurses, is
quite different.11 Cultural safety shifts the role of culture away
from a check-list approach based on a persons ethnic back-
ground and toward a critical examination of the power imbal-
ances in health care encounters between indigenous patients
and non-indigenous health care providers. When viewed in
this way, culturally safe health care becomes a core principle
for the reorientation of health services to better meet the needs
of vulnerable groups, irrespective of their ethnic background.
We need to move beyond patientprovider interactions in
developing a policy-informing agenda on access. Known fa-
cilitators of access are the establishment of community-gov-
erned health services, a robust indigenous managerial and
clinical workforce and the ability to deliver models of care
that embrace indigenous knowledge systems.12 The interpre-
tive synthesis of the literature about the barriers to access for
vulnerable groups by Dixon-Woods and colleagues has led to
the development of the useful concepts of navigation and
permeability.13 Navigation requires an awareness of the
available services and the mobilization of personal and health
service resources to provide access, such as transport, min-
imal out-of-pocket cost and flexible hours. Permeable ser-
vices require little negotiation for entry and a minimal level of
understanding of how the system works. These services may
include having welcoming physical spaces, open-door pol-
icies and reception staff who are known to the community.
Measures of health system performance are increasingly
used to improve access and quality of care. The US Indian
Health Service has invested substantially in information tech-
From the George Institute for International Health (Peiris, Cass), Sydney; the
Centre for Indigenous Vascular and Diabetes Research (Brown), Baker IDI
Heart and Diabetes Institute, Alice Springs; The Poche Centre for Indigenous
Health (Cass), University of Sydney, Sydney, Australia
985
Commentary
nology to support macrosystem monitoring of quality meas-
ures.14 The Australian government is developing quality indi-
cator programs for Aboriginal health services. Although these
approaches are valuable, caution is needed in their applica-
tion. In a review of indigenous health performance measure-
ment systems, Smylie and colleagues argue that the develop-
ment of these macrosystem measures, which are usually
based on physical and disease variables, often come at the
expense of developing locally specific health indicators for
indigenous populations.15 The article by Gao and colleagues
exemplifies the problem discussed by Anderson and col-
leagues5 in the classification of ethnicity, particularly for peo-
ple of mixed descent. The classification of non-status First
Nations and Metis people as non-Aboriginal is epidemiolog-
ically expedient, but it raises concerns about equity. Support
for local measurement systems responsive to indigenous peo-
ple and to their health service priorities can complement con-
ventional performance measures and ensure valid interpreta-
tion of those measurements.
Our list of barriers and facilitators is not exhaustive. A
key consideration is the need for greater clarity in how we
conceptualize barriers, their defining characteristics and their
causes. Closely related is the need to move beyond explana-
tory models, which focus on deficiencies in individuals and
services, and toward a better understanding of existing facili-
tators to improved access and quality. The research on which
to base policy is a labyrinthine mix of qualitative studies,
audits and surveys, program evaluations, advocacy, quality
improvement projects, nonsystematic topic reviews and
opinion pieces. Opinion pieces are often key sources of in-
digenous perspectives but are poorly represented and under-
valued in the scientific literature. Much of this disparate liter-
ature is locally specific, small in scale and is often not
amenable to the reductionism of conventional systematic re-
views. This makes national and international extrapolation
difficult and poses dilemmas for the development of
evidence-based policy.
In Canada, Australia, New Zealand and the US, inequities
in access to health care and outcomes for indigenous people
have been well-characterized. To close these gaps, we need
to document disparities and understand their causes more
precisely and make collaborative changes. Such changes are
often resisted by institutional, political, structural, social and
cultural forces. As indicated by an Aboriginal man with end-
stage kidney disease interviewed for the Improving Access
to Kidney Transplants study16 when discussing communi-
cation with his kidney specialists: You dont go knocking
on their door, [thats the] danger one. The door is locked. International Health, PO Box M201, Missenden Rd., Sydney NSW
They sit behind closed doors. If we are able to open these
986 CMAJ NOVEMBER 4, 2008 179(10)
doors, our health care systems may perform better for the
most vulnerable.
Competing interests: None declared.
Contributors: Each of the authors contributed to the content of the article,
revised it critically and approved the final version for publication.
Acknowledgements: We thank Dr. Peter Arnold for his help in editing this
article.
David Peiris is supported by a scholarship from the New South Wales
Clinical Excellence Commission. Alan Cass is the recipient of a National
Health and Medical Research Council Senior Research Fellowship.
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Correspondence to: Dr. Alan Cass, The George Institute for
2050, Australia; fax 61 2 9993 4502; acass@george.org.au